APPROACH TO TACHYCARDIA Goals To make tachycardia less

APPROACH TO TACHYCARDIA

Goals § To make tachycardia “less scary” § To give you an approach to tachycardia § Pearls of interpretating 12 -2 -9

Tachycardia • • Definition – HR > 100 bpm – Or Cycle Length < 600 msec Narrow complex tachycardia – • QRS < 120 msec Wide complex tachycardia – QRS > 120 msec

Narrow Complex Tachycardia What are the questions to ask? § Is the rhythm regular or irregular? § Is there P with everything QRS or is P > QRS? § § How did the tachycardia start, with PAC or PVCs? How did the tachycardia terminate, with P or QRS?

Sinus tachycardia There is one P with one QRS §Regular rhythm §

Atrial Flutter More P then QRS, 3: 1, 4: 1 ratio § Regular Rhythm § Saw tooth appearance §

Atrial Tachycardia P before QRS. (may have different p morphology) • May be indistinguishable from sinus tachycardia • Usually abrupt onset and offset (as opposed to gradual with sinus tachycardia •

Multifocal atrial tachycardia • One P wave with one QRS • Irregular rhythm • Varying p wave morphology and PR segments • Usually Seen in patients with lung disease

Questions? 12 -2 -9

Atrial fibrillation No clear visible P waves § Irregular rhythm §

Atrial Fibrillation

Supraventricular tachycardia Narrow complex, regular § Starts and stops suddenly, usually with PAC § May see inverted p waves in the ST segment or T wave §

Narrow Complex Tachycardia Regular P before QRS: Sinus tachy Atach Aflutter with 1: 1 AV P>QRS: Aflutter Irregular No p wave: SVT Atach ? very fast AFIB Irregularly Irregular: Regularly Irregular: • Afib • Aflutter with variable • Multifocal Atach response • Atach with var response

Questions? Click to edit the outline text format Second Outline Level Third Outline Level 12 -2 -9 Fourth Outline Level Fifth Outline Level Sixth

WIDE COMPLEX TACHYCARDIAS

Ventricular tachycardia

Ventricular tachycardia Wide complex tachycardia • May be monomorphic or polymorphic • Usually preceded by PVC • Look for more QRS then P •

Polymorphic VT/Torsade de Pointes Classic pattern of “twisting” of QRS in an axis • Can be seen with electrolyte abnormalities- Hypo K, Hypo Mg or Long QT syndrome • Typical onset- bradycardia, long R-R interval followed by premature ventricular complex (PVC) •

SVT with Aberrancy SVT with native bundle branch block or rate-related aberrancy • May be difficult to distinguish VT from SVT with aberrancy even with most skilled Electrophysiologists •

Ventricular Fibrillation No clear visible P §Very fast > 300 bpm §

** This may not be ASYSTOLE • ALWAYS check that leads are properly put on • ALWAYS check gain is not too low!

Wide Complex tachycardia

Questions ?